IR 05000458/2019001

NRC Integrated Inspection Report 05000458/2019001

ML19130A200
Person / Time
Site:	River Bend
Issue date:	05/10/2019
From:	Jason Kozal Division of Nuclear Materials Safety IV
To:	Vercelli S Entergy Operations
References
IR 2019001
Download: ML19130A200 (25)

Text

SUBJECT:

RIVER BEND STATION - NRC INTEGRATED INSPECTION REPORT 05000458/2019001

Dear Mr. Vercelli:

On March 31, 2019, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your River Bend Station. On April 24, 2019, the NRC inspectors discussed the results of this inspection with Mr. Kent Scott, General Manager of Plant Operations, and other members of your staff. The results of this inspection are documented in the enclosed report.

NRC inspectors documented two findings of very low safety significance (Green) in this report.

These findings involved violations of NRC requirements.

If you contest the violations or significance of the violations documented in this inspection report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; and the NRC resident inspector at River Bend Station.

If you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the NRC resident inspector at River Bend Station. This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely,

/RA/

Jason W. Kozal, Chief Reactor Projects Branch C Docket No. 05000458 License No. NPF-47 Enclosure:

Inspection Report 05000458/2019001

U.S. NUCLEAR REGULATORY COMMISSION

Inspection Report

Docket Number(s): 05000458 License Number(s): NPF-47 Report Number(s): 05000458/2019001 Enterprise Identifier: I-2019-001-0009 Licensee: Entergy Operations, Inc.

Facility: River Bend Station Location: St. Francisville, LA Inspection Dates: January 1, 2019 to March 31, 2019 Inspectors: L. Merker, Senior Resident Inspector (BWR/TL)

B. Parks, Resident Inspector (BWR)

T. DeBey, Resident Inspector (BWR)

Approved By: Jason W. Kozal Chief, Reactor Projects Branch C Division of Reactor Projects Enclosure

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a quarterly inspection at River Bend Station in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information. Violations and other additional items being considered in the NRCs assessment are summarized in the table below.

List of Findings and Violations Failure to Maintain Appropriate Surveillance and Maintenance Procedures for the Division III Emergency Diesel Generator Cornerstone Significance Cross-cutting Report Aspect Section Mitigating Green [H.11] - 71152 Systems NCV 05000458/2019001-01 Challenge Closed the Unknown The inspectors identified a Green, non-cited violation of 10 CFR Part 50, Appendix B,

Criterion V, Instructions, Procedures, and Drawings, for the licensees failure to prescribe instructions appropriate to the circumstances, including appropriate quantitative or qualitative acceptance criteria, for an activity affecting quality. Specifically, instructions for surveillance and maintenance work on the turbocharger lubricating oil system of the Division III emergency diesel generator, which is an activity affecting quality, did not specify acceptance criterion for the DC lubricating pump motor continuity check nor did they require a post maintenance demonstration that the motor could run. As a result, the Division III emergency diesel generator was declared inoperable on November 28, 2018.

Inadvertent Initiation of Reactor Core Isolation Cooling due to Personnel Error Cornerstone Significance Cross-cutting Report Aspect Section Initiating Green [H.5] - Work 71153 Events NCV 05000458/2019001-02 Management Closed The inspectors reviewed a self-revealed, Green, non-cited violation of 10 CFR Part 50,

Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the licensees failure to accomplish an activity affecting quality in accordance with a prescribed procedure.

Specifically, while conducting surveillance testing on the reactor core isolation cooling (RCIC)system, technicians installed an incorrect test fixture and caused an inadvertent injection of RCIC into the reactor vessel.

Additional Tracking Items Type Issue number Title Inspection Status Procedure LER 05000458/2018-007-00 Manual Reactor Scram due 71153 Closed to Reactor Recirculation Pump Trip Caused by Transformer Failure LER 05000458/2018-008-00 Potential Loss of Safety 71153 Closed Function and Unanalyzed Condition due to Legacy Design Deficiency in Control Building HVAC LER 05000458/2018-009-00 Inadvertent Initiation of 71153 Closed Reactor Core Isolation Cooling due to Personnel Error

PLANT STATUS

River Bend Station began the inspection period at rated thermal power. On January 4, 2019, the unit was down powered to 85 percent to conduct a seal repair on main feedwater pump 1A. The unit was returned to rated thermal power on January 7, 2019. On January 12, 2019, the unit was down powered to 70 percent because of an issue with the inboard main steam isolation valve D solenoid pilot valve. The unit was returned to 75 percent power on January 13, 2019. The unit was shut down on March 30, 2019, to begin refueling outage RF-20 and remained shut down for the remainder of the inspection period.

INSPECTION SCOPES

Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The inspectors performed plant status activities described in IMC 2515, Appendix D, Plant Status, and conducted routine reviews using IP 71152, Problem Identification and Resolution. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.

71111.01 - Adverse Weather Protection External Flooding Sample (IP Section 03.04)

The inspectors evaluated the site's readiness to cope with external flooding for the following areas:

• Control building on January 23, 2019

• Division I emergency diesel generator room on January 23, 2019

• Division II emergency diesel generator room on January 23, 2019

• Division III emergency diesel generator room on January 23, 2019

71111.04 - Equipment Alignment Partial Walkdown (IP Section 02.01)

The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:

(1) Division II 125 VDC system on January 17, 2019

(2) Low pressure core spray system on March 7, 2019

(3) Division I 125 VDC system on March 19, 2019

71111.04S - Equipment Alignment Complete Walkdown (IP Section 02.02)

The inspectors evaluated system configurations during a complete walkdown of the high pressure core spray system on January 30, 2019.

71111.05A - Fire Protection (Annual) Annual Inspection (IP Section 03.02)

The inspectors evaluated fire brigade performance on January 30, 2019.

71111.05Q - Fire Protection Quarterly Inspection (IP Section 03.01)

The inspectors evaluated fire protection program implementation in the following selected areas:

(1) High pressure core spray room, fire areas AB-2/Z-1 and AB-2/Z-2, on January 30, 2019

(2) Standby liquid control area, fire area RC-4/Z-4, on January 31, 2019

(3) Division I, II, and III battery rooms, fire areas C-18, C-19, and C-21, on February 1, 2019

(4) Low pressure core spray pump room, fire area AB-6/Z-1, on March 7, 2019

71111.06 - Flood Protection Measures Inspection Activities - Internal Flooding (IP Section 02.02a.)

The inspectors evaluated internal flooding mitigation protections in the:

• High pressure core spray pump room on March 18, 2019 Inspection Activities - Underground Cables (IP Section 02.02c.) (1 Sample)

The inspectors evaluated cable submergence protection in:

• Electrical manhole EMH2A on March 14, 2019

• Electrical manhole EMH103 on March 14, 2019

71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01)

The inspectors observed and evaluated licensed operator performance in the main control room during a reactor power maneuver on January 4, 2019.

Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)

The inspectors observed and evaluated licensed operator requalification training in the simulator on February 12, 2019.

71111.12 - Maintenance Effectiveness Routine Maintenance Effectiveness Inspection (IP Section 02.01)

The inspectors evaluated the effectiveness of routine maintenance activities associated with the following equipment and/or safety significant functions:

(1) Functional failure review of the high pressure core spray system on March 6, 2019

(2) Functional failure review of containment unit cooler 1A on March 21, 2019

(3) Functional failure review of the Division I emergency diesel generator on March 25, 2019

71111.13 - Maintenance Risk Assessments and Emergent Work Control Risk Assessment and Management Sample (IP Section 03.01)

The inspectors evaluated the risk assessments for the following planned and emergent work activities:

(1) Yellow risk during surveillance testing of low pressure coolant injection pump A on January 8, 2019

(2) Yellow risk during surveillance testing of reactor core isolation cooling system on January 15, 2019

(3) Yellow risk during inspection of Division I standby service water system on February 8, 2019

(4) Yellow risk during inspection of Division II standby service water system on February 21, 2019

71111.15 - Operability Determinations and Functionality Assessments Sample Selection (IP Section 02.01)

The inspectors evaluated the following operability determinations and functionality assessments:

(1) Division I control building air conditioning system after failure of air handling unit 2A to close electrically in the test position on March 4, 2019

(2) Division I residual heat removal heat exchangers following thermal performance testing on March 11, 2019

(3) Containment unit cooler 1A low air flow conditions on March 14, 2019

(4) Division II hydrogen igniters surveillance testing results on March 21, 2019

(5) Division II main steam positive leakage control system after failure of trip unit card on March 25, 2019

71111.19 - Post Maintenance Testing Post Maintenance Test Sample (IP Section 03.01)

The inspectors evaluated the following post maintenance tests:

(1) Work Order 00514462, SVV-MOV1B Major Actuator Inspection / Div 2, following actuator inspection of main steam line pressure relief isolation valve SVV-MOV1B on February 20, 2019

(2) Work Order 00514461, SWP-MOV503B Major Actuator Inspection / HVR-UC1B, following actuator inspection of containment unit cooler 1B return header inboard containment isolation valve SWP-MOV503B on February 20, 2019

(3) Work Order 52829384, IAS-C2A - Perform 4,000 Hr Inspection, following 4,000 hour0 days <br />0 hours <br />0 weeks <br />0 months <br /> preventive maintenance of instrument air compressor 2A on February 22, 2019

(4) STP-403-0301, Revision 15, Containment Unit Cooler HVR-UC1A Flow Rate Verification, following cooling coil cleaning due to low air flow conditions on March 14, 2019

(5) STP-251-3205, Revision 16, Diesel Fire Pump Operational Test, following system maintenance on fire pump engine 1B on March 18, 2019

71111.22 - Surveillance Testing The inspectors evaluated the following surveillance tests: In Service Testing (IST) (IP Section 03.01)

(1) STP-201-6310, Revision 311, SLC Pump and Valve Operability Test, on January 31, 2019

(2) STP-205-6301, Revision 25, LPCS Pump and Valve Operability Test, on March 7, 2019

Surveillance Testing (IP Section 03.01) (4 Samples)

(1) STP-309-0201, Revision 062, Division I Diesel Generator Operability Test, on January 7, 2019

(2) STP-256-0201, Revision 304, Div I SWP Valve Lineup Verification, on January 10, 2019

(3) STP-051-4504, Revision 301, NSSSS-Reactor Vessel Water Level-Low Low, Level 2; Low Low Low, Level 1, Channel Functional Test (B21-N682D, B21-N681D),on January 23, 2019

(4) STP-203-0201, Revision 308, HPCS Piping Water Fill and Valve Position Verification, on January 29, 2019

71114.06 - Drill Evaluation Drill and/or Simulator-Based Licensed Operator Requalification Training (IP Section 02.01)

The inspectors evaluated an emergency preparedness training drill on March 12,

OTHER ACTIVITIES - BASELINE

===71151 - Performance Indicator Verification The inspectors verified licensee performance indicators submittals listed below:

IE01: Unplanned Scrams per 7000 Critical Hours Sample (IP Section 02.01) ===

(01/01/2018-12/31/2018)

IE03: Unplanned Power Changes per 7000 Critical Hours Sample (IP Section 02.02)

(1 Sample)

(01/01/2018-12/31/2018)

IE04: Unplanned Scrams with Complications (USwC) Sample (IP Section 02.03) (1 Sample)

(01/01/2018-12/31/2018)

71152 - Problem Identification and Resolution Annual Follow-up of Selected Issues (IP Section 02.03)

The inspectors reviewed the licensees implementation of its corrective action program related to the following issue:

• Turbocharger lubricating oil pump failures on the Division III emergency diesel generator resulting in inoperability of the diesel generator

71153 - Follow-up of Events and Notices of Enforcement Discretion Event Report (IP Section 03.02)

The inspectors evaluated the following licensee event reports (LERs) which can be accessed at https://lersearch.inl.gov/LERSearchCriteria.aspx:

(1) LER 05000458/2018-007-00, Manual Reactor Scram due to Reactor Recirculation Pump Trip Caused by Transformer Failure on February 1, 2018 (ADAMS Accession: ML18304A436):

The inspectors reviewed this LER and closed it to non-cited violation 05000458/2018012-04 issued in Inspection Report 05000458/2018012 (ADAMS Accession: ML18261A111).

(2) LER 05000458/2018-008-00, Potential Loss of Safety Function and Unanalyzed Condition due to Legacy Design Deficiency in Control Building HVAC on September 25, 2018 (ADAMS Accession: ML18324A744):

The inspectors reviewed this LER and closed it to the licensee-identified violation issued in Inspection Report 05000458/2018003 (ADAMS Accession: ML18313A028).

(3) LER 05000458/2018-009-00, Inadvertent Initiation of Reactor Core Isolation Cooling due to Personnel Error on November 2, 2018 (ADAMS Accession: ML19003A143):

The circumstances surrounding this LER are documented in the Inspection Results section.

INSPECTION RESULTS

Failure to Maintain Appropriate Surveillance and Maintenance Procedures for the Division III Emergency Diesel Generator Cornerstone Significance Cross-cutting Report Aspect Section Mitigating Green [H.11] - 71152 Systems NCV 05000458/2019001-01 Challenge the Closed Unknown The inspectors identified a Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the licensees failure to prescribe instructions appropriate to the circumstances, including appropriate quantitative or qualitative acceptance criteria, for an activity affecting quality. Specifically, instructions for surveillance and maintenance work on the turbocharger lubricating oil system of the Division III emergency diesel generator, which is an activity affecting quality, did not specify acceptance criterion for the DC lubricating pump motor continuity check nor did they require a post maintenance demonstration that the motor could run. As a result, the Division III emergency diesel generator was declared inoperable on November 28, 2018.

Description:

On November 28, 2018, operators in the River Bend Station (RBS) main control room received an alarm, Div III D/G System Trouble, for the Division III high pressure core spray (HPCS) emergency diesel generator. Investigation into the cause of the alarm revealed that both turbocharger lubricating oil pumps had failed, rendering the diesel generator inoperable. The inoperability lasted for about 8.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> while the oil pumps were repaired. Operability of the HPCS system during a loss of offsite power requires operability of its dedicated diesel generator. Since offsite power was available on November 28, 2018, the HPCS system remained operable. The HPCS diesel generator is one of three emergency diesel generators that are required to be operable by RBS Technical Specification 3.8.1. Per RBS Procedure SOP-0052, HPCS Diesel Generator (Sys #309), Revision 58, for Division III (HPCS) diesel generator operation, no planned starts of the engine should be performed without a turbocharger lubricating oil pump operating. The procedure also stated that if both (AC and DC-powered) turbocharger lubricating pumps are out of service, the diesel engine is not available for operation. Lubrication of the diesel engine turbocharger is supplied by an engine-driven pump while the engine is running and an AC electric pump when the engine is stopped. If the AC pump would stop while the engine is not running, a DC electric pump is designed to start so that lubricating oil flow to the turbocharger is maintained. The turbocharger lubrication system has two primary functions:

(1) lubrication of the turbocharger bearings and

(2) cooling of the turbocharger.

Condition Report CR-RBS-2018-06363 documented the loss of turbocharger lubricating oil flow to the HPCS diesel generator that resulted in its inoperability on November 28, 2018.

Troubleshooting by station personnel revealed that one of the two brushes on the DC lubricating pump motor was mispositioned, causing the motor to fail. Questioning from the inspectors revealed that the stations surveillance and maintenance of the DC motor was done on a biennial basis and was not appropriate to detect the mispositioned brush or to verify the ability of the motor to run after the electrical surveillance. Additionally, the licensees work order instructions were not appropriate and did not contain appropriate quantitative or qualitative acceptance criteria. Further inspector questioning revealed that the same instruction inadequacies also existed for the HPCS emergency diesel generator DC motor for the associated circulating oil lubrication system. It is likely that the DC motor was not able to operate from September 18, 2017 (the most recent inspection and preventive maintenance date), until November 28, 2018.

Corrective Actions: The licensee removed the DC motor from the diesel engine, reinstalled the mispositioned brush, returned the motor to the diesel engine, and performed a successful post maintenance test. Other corrective actions that the licensee is considering include performing monthly (vs. biennial) functional testing of the DC oil pump, requiring removal of the DC motor in order to do the brush inspections, improving the DC motor inspection process, sharing the lessons learned from this event, and revising the procedural requirement for declaring the diesel engine inoperable when the turbocharger lubricating oil flow is lost.

Corrective Action Reference: CR-RBS-2018-06363

Performance Assessment:

Performance Deficiency: The failure to prescribe instructions appropriate to the circumstances, including appropriate quantitative or qualitative acceptance criteria, for surveillance and maintenance of the turbocharger lubricating oil system of the Division III (HPCS) emergency diesel generator, resulting in inoperability of the diesel generator, was a performance deficiency.

Screening: The inspectors determined the performance deficiency was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, instructions for surveillance and maintenance work on the turbocharger lubricating oil system of the Division III emergency diesel generator, which is an activity affecting quality, did not specify acceptance criterion for the DC lubricating pump motor continuity check nor did they require a post maintenance demonstration that the motor could run. As a result, the Division III emergency diesel generator was declared inoperable on November 28, 2018.

Significance: The inspectors assessed the significance of the finding using NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, Exhibit 2, Mitigating Systems Screening Questions, dated July 1, 2012.

The finding was determined to be of very low safety significance (Green) because it did not represent a deficiency affecting the design or qualification of a mitigating structure, system, or component; did not represent a loss of system and/or function; did not represent an actual loss of function of at least a single train for more than its technical specification allowed outage time or two separate safety systems out-of-service for more than its technical specification allowed outage time; and did not represent an actual loss of function of one or more non-technical specification trains of equipment designated as high safety-significant in accordance with the licensees maintenance rule program for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.

Cross-cutting Aspect: The finding had a cross-cutting aspect in the area of human performance, challenge the unknown, because the licensee did not stop when faced with uncertain conditions, and risks were not evaluated and managed before proceeding. Specifically, the licensee did not question the lack of acceptance criterion for the DC lubricating pump motor continuity check or post maintenance demonstration that the motor could run [H.11].

Enforcement:

Violation: Title 10 of the Code of Federal Regulations, Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances. The instructions, procedures, or drawings shall include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished.

Contrary to the above, on September 18, 2017, the surveillance and maintenance procedure for the turbocharger lubricating oil system of the Division III emergency diesel generator, which is an activity affecting quality, was not appropriate to the circumstances because it did not include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished. Specifically, instructions for surveillance and maintenance work on the turbocharger lubricating oil system of the Division III emergency diesel generator, which is an activity affecting quality, did not specify acceptance criterion for the DC lubricating pump motor continuity check nor did they require a post maintenance demonstration that the motor could run. As a result, the Division III emergency diesel generator was declared inoperable on November 28, 2018.

Enforcement Action: This violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.

Inadvertent Initiation of Reactor Core Isolation Cooling due to Personnel Error Cornerstone Significance Cross-cutting Report Aspect Section Initiating Events Green [H.5] - Work 71153 NCV 05000458/2019001-02 Management Closed The inspectors reviewed a self-revealed, Green, non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the licensees failure to accomplish an activity affecting quality in accordance with a prescribed procedure.

Specifically, while conducting surveillance testing on the reactor core isolation cooling (RCIC)system, technicians installed an incorrect test fixture and caused an inadvertent injection of RCIC into the reactor vessel.

Description:

At 3:53 a.m. on November 2, 2018, during performance of surveillance Procedure STP-051-4524, ECCS/RCIC-Reactor Vessel Water Level-Low Low, Level 2; Low Low Low, Level 1; Channel Functional Test (B21-N692E, B21-N691E), Revision 5, RCIC initiated and began injecting water into the reactor vessel. After verifying that the initiation was inadvertent, operators tripped the RCIC turbine in accordance with Procedure AOP-0034, Inadvertent Initiation of an ECCS System or RCIC, Revision 2, and declared RCIC inoperable. Operators subsequently restored RCIC to a normal standby lineup and returned the system to operable status.

Subsequent investigation determined that technicians caused the initiation by installing an incorrect test fixture into the system. Procedure STP-051-4524, Step 7.1.9, instructed technicians to connect a red A/B contact test fixture and Simpson Multimeter to test jack E51A-J1, RCIC LOGIC A TEST. Instead of installing that contact test fixture, technicians installed a green B/C contact test fixture. The installation of the green B/C contact test fixture into jack E51A-J1 satisfied the coincidence logic for RCIC initiation, causing the inadvertent injection into the core.

The licensee conducted a review of the event and identified multiple deficiencies in the area of work management. In an attempt to recover lost time in the work schedule, the nightshift supervisor directed the technicians to perform an unusually high number of surveillance items in one shift. The supervisor assigned the items at the beginning of the shift and proceeded to focus on other plant issues for the remainder of the night, failing to sufficiently engage with and oversee the risk-significant testing that was being carried out. The technicians failed to fill out the required pre-job brief checklist and the peer reviewing technician failed to conduct an adequate peer check prior to the critical step.

Corrective Actions: The licensee restored RCIC to operable status after the event and issued corrective actions to augment supervisory oversight of pre-job briefs and testing evolutions.

Corrective Action Reference: CR-RBS-2018-05854

Performance Assessment:

Performance Deficiency: The failure to accomplish an activity affecting quality in accordance with a prescribed procedure was a performance deficiency.

Screening: The inspectors determined the performance deficiency was more than minor, and therefore a finding, because it was associated with the human performance attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, by failing to properly complete the steps of the surveillance test procedure, the licensee caused an inadvertent RCIC injection into the reactor vessel.

Significance: The inspectors assessed the significance of the finding using NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, Exhibit 1, Initiating Events Screening Questions, dated June 19, 2012. The inspectors determined that the finding was of very low safety significance (Green) because the finding did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition.

Cross-cutting Aspect: The finding had a cross-cutting aspect in the area of human performance, work management, because the licensee failed to implement a process of planning, controlling, and executing work activities such that nuclear safety was the overriding priority. Specifically, the licensee conducted a risk-significant evolution with inadequate concurrent peer check and insufficient supervisory oversight [H.5].

Enforcement:

Violation: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings.

Contrary to the above, on November 2, 2018, the licensee failed to accomplish an activity affecting quality in accordance with a prescribed procedure appropriate to the circumstances. Specifically, during surveillance testing of RCIC, which is an activity affecting quality, the licensee violated the surveillance test procedure by installing the wrong test fixture into the system.

Enforcement Action: This violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.

EXIT MEETINGS AND DEBRIEFS

The inspectors verified no proprietary information was retained or documented in this report.

• On April 24, 2019, the inspector presented the quarterly resident inspector inspection results to Mr. K. Scott, General Manager of Plant Operations, and other members of the licensee staff.

DOCUMENTS REVIEWED

71111.01 - Adverse Weather Protection

Condition Reports (CR-RBS-)

2018-04723 2018-05237 2019-00366

Engineering

Reports

Number Title Revision

RBS-CS-15-00008 Fukushima Flooding Integrated Assessment Report 000

RBS-SA-17-00001 2017 Focused Evaluation for External Flooding 000

Procedures

Number Title Revision

AOP-0029 Severe Weather Operation 040

OSP-0070 Preparation for Mississippi River Flooding 000

71111.04 - Equipment Alignment

Condition Reports (CR-RBS-)

2016-06474 2017-08540 2018-01305 2018-01850 2018-02155

2018-02517 2018-03476 2018-03786 2018-04582 2018-05038

2018-05510 2018-05862 2019-00125 2019-01052 2019-01519

Procedures

Number Title Revision

AOP-0014 Loss of 125 VDC 027

R-STM-0305 DC Distribution 006

SOP-0030 High Pressure Core Spray 034

SOP-0032 Low Pressure Core Spray 025

SOP-0049 125 VDC System (Sys #305) 043

STP-203-0201 HPCS Piping Water Fill and Valve Position Verification 308

STP-203-6501 HPCS Pump and Valve Operability Test 012

71111.05AQ - Fire Protection Annual/Quarterly

Calculation

Number Title Revision

G13.18.12.2-022 River Bend Station Combustible Loading 005

Condition Reports (CR-RBS-)

2016-07444 2017-06932 2018-00526 2018-01736 2019-00347

Miscellaneous

Documents

Number Title Revision

EN-TQ-125 Fire Brigade Drills 007

EN-TQ-125, Fire Drill Scenario 007

Procedures

Number Title Revision

AB-070-501 LPCS Pump Room Fire Area AB-6/Z-1 004

AB-070-506 HPCS Pump Room Fire Area AB-2/Z-1 004

AB-095-517 HPCS Piping Area Fire Area AB-2/Z-2 004

CB-116-133 Battery 1A Room Fire Area C-18 004

CB-116-134 Battery 1B Room Fire Area C-19 004

CB-116-136 HPCS Battery Room Fire Area C-21 004

RB-141-008 SLC Area Fire Area RC-4/Z-4 003

STP-000-3602 Fire Barrier Visual Inspection 017

71111.06 - Flood Protection Measures

Calculations

Number Title Revision

PN-314 Moderate Energy Line Crack Flow Rates 00

PN-317 Max Flood Elevations for Moderate Energy Line Cracks 01

in Cat I Structures

Drawings

Number Title Revision

210-EB-40A-7 Floor & Equipment Drainage Aux Bldg EL 70-0 SH-1

210-EB-40B-9 Floor & Equipment Drainage Aux Bldg El 70-0 SH-2

210-EB-40C-5 Floor & Equipment Drainage Aux Bldg El 95-9 SH-3

210-EB-40D-7 Floor & Equipment Drainage Aux Bldg El 95-9 SH-4

EE-032J Arrangement - Manholes Plan and Details 8

PID-32-09J Engineering P&I Diagram System 609 Drains - Floor 22

and Equipment

PID-32-09K Engineering P&I Diagram System 609 Drains - Floor 19

and Equipment

Procedure

Number Title Revision

EN-DC-346 Cable Reliability Program 7

Work Orders

2867111 52869316

71111.11 - Licensed Operator Requalification Program and Licensed Operator Performance

Condition Reports (CR-RBS-)

2018-00225 2018-01263 2018-01576 2018-01690 2018-03330

2018-06304

Miscellaneous

Documents

Number Title Revision

EIP-2-0001 User Aid 1 F

RSMS-OOPS-19- 19-1 As Found Evaluation 1

Procedures

Number Title Revision

AOP-0001 Reactor Scram 37

AOP-0002 Main Turbine and Generator Trips 30

AOP-0003 Automatic Isolations 38

AOP-0005 Loss of Main Condenser Vacuum, Trip of Circulating 26

Water Pump

AOP-0016 Loss of Standby Service Water 22

AOP-0017 Reactor Pressure Control Malfunctions 2

AOP-0050 Station Blackout 62

EN-OP-115 Conduct of Operations 25

EOP-0001 RPV Control 281

EOP-0002 Primary Containment Control 17

EOP-0003 Secondary Containment and Radioactive Release 18

Control

EOP-0004 Contingencies 16

GOP-0002 Power Decrease/Plant Shutdown 082

GOP-0005 Power Maneuvering 330

SOP-0003 Reactor Recirculation System 315

SOP-0009 Reactor Feedwater System 079

SOP-0035 Reactor Core Isolation Cooling System 56

SOP-0053 Standby Diesel Generator and Auxiliaries 39

71111.12 - Maintenance Effectiveness

Condition Reports (CR-RBS-)

2017-04898 2017-07080 2017-07111 2017-07532 2017-07983

2017-08041 2017-08048 2017-08190 2017-08529 2017-08561

2018-00170 2018-00635 2018-01002 2018-01805 2018-01982

2018-01987 2018-02314 2018-02524 2018-03780 2018-03895

2018-04275 2018-04276 2018-04751 2018-04992 2018-05603

2018-05618 2018-05698 2018-05709 2018-05752 2018-05764

2018-05854 2018-05857 2018-05866 2018-05876 2019-00034

2019-00229 2019-00732 2019-00750 2019-00826 2019-01230

2019-01246 2019-01275 2019-01362 2019-01386 2019-01422

2019-01431 2019-01437

Miscellaneous

Document

Number Title Date

System Health Standby Emergency Diesel Generators - Division I, II, & 03/19/2019

Report: 309 and III and HVAC

405

Procedures

Number Title Revision

EN-DC-203 Maintenance Rule Program 4

EN-DC-204 Maintenance Rule Scope and Basis 4

EN-DC-205 Maintenance Rule Monitoring 6

EN-DC-206 Maintenance Rule (a)(1) Process 3

SOP-0030 High Pressure Core Spray (Sys #203) 34

SOP-0059 Containment HVAC System (Sys #403) 38

Work Order 00483043

71111.13 - Maintenance Risk Assessments and Emergent Work Control

Condition Reports (CR-RBS-)

2019-00035 2019-00068

Procedures

Number Title Revision

ADM-0096 Risk Management Program Implementation and On-line 327

Maintenance Risk Assessment

EN-OP-119 Protected Equipment Postings 010

EN-WM-104 On Line Risk Assessment 018

Procedures

Number Title Revision

STP-207-4536 RCIC Isolation RCIC Steam Line Flow High Channel 302

Functional Test (E31-N683A, E31-N690A, E51A-K64)

STP-207-4539 RCIC Isolation RCIC Steam Supply Pressure Low 301

Channel Functional Test (E31-N685B)

STP-207-4549 RCIC Isolation RCIC RHR Steam Line Flow High 011

Channel Functional Test (E31-N684B, E31-N691B)

Work Orders

2716192 52847802 52847803 52847804

71111.15 - Operability Determinations and Functionality Assessments

Calculation

Number Title Revision

G13.18.14.1-037 Residual Heat Removal System Heat Exchanger 0

Performance Guidance

Condition Reports (CR-RBS-)

2017-01774 2017-04636 2018-06569 2018-06683 2019-00744

2019-00868 2019-00947 2019-01265 2019-01362 2019-01386

2019-01510

Drawings

Number Title Revision

ESK-06HVC02 Elementary Diagram 480V Switchgear Control Room Air 32

Handling Unit ACU2A

GE-793E922A Main Steam Positive Leakage Control System 3

Miscellaneous

Documents

Number Title Revision

21.432-000-019 RHR Heat Exchanger Calculated Performance 1

211.161-997-179 Glow Plug Equivalency Evaluation for Hydrogen Igniter 1

Assembly #6043 Autolite Model 1106 vs. Autolite

Model 1109 AC DELCO 7G, and 12G

EC-34819 Issue Calculation G13.18.14.1-037 R0, Residual Heat 0

Removal System Heat Exchanger Performance

Guidance

Procedures

Number Title Revision

EN-OP-104 Operability Determination Process 16

SOP-0040 Hydrogen Mixing, Purge, Recombiners, and Igniters 306

SOP-0059 Containment HVAC System 38

STP-000-0001 Daily Operating Logs 84

STP-000-0001 Daily Operating Logs 85

STP-208-4208 Containment System/MSIV Positive Leakage Control- 13

Reactor-Steam Line Differential Pressure Channel

Calibration Test (E33-N623, E33-R623, E33-N629,

E33-N630, E33-K623)

STP-254-1402 Div II Hydrogen Igniter Train Current and Voltage Check 24

STP-254-1402 Div II Hydrogen Igniter Train Current and Voltage Check 26

STP-403-0301 Containment Unit Cooler HVR-UC1A Flow Rate 15

Verification

Work Orders

00478283 00513411 00514664 00514722 00514723 00520091 00520586

00769860 52624439 52687133 52751160 52753000 52843654

71111.19 - Post Maintenance Testing

Condition Reports (CR-RBS-)

2001-01031 2008-05122 2016-01725 2019-01362 2019-01386

Miscellaneous

Document

Number Title Revision

CEP-IST-4 Standard on Inservice Testing 309

Procedures

Number Title Revision

EN-MA-118 Foreign Material Exclusion 15

EN-MA-141 Limitorque Valve Operator Model SMB/SB/SBD-000 12

Through 5 MOV and HBC Periodic Inspection

SOP-0037 Fire Protection Water System Operating Procedure 43

(Sys #251)

SOP-0059 Containment HVAC System 38

STP-251-3205 Diesel Fire Pump Operational Test 16

STP-251-7608 FPW-P1B Fire Pump Engine Maintenance and 4

Inspection

STP-403-0301 Containment Unit Cooler HVR-UC1A Flow Rate 15

Verification

Work Orders

00514461 00514462 00520586 52760448 52816820 52820964 52829384

71111.20 - Refueling and Other Outage Activities

Condition Reports (CR-RBS-)

2019-01756 2019-01792 2019-01806

Miscellaneous

Document

Number Title Date

Outage Risk Assessment Team RF-20 Outage Report 03/18/2019

Procedures

Number Title Revision

CMP-0102 Reactor Vessel Disassembly 23

EN-OU-108 Shutdown Safety Management Program (SSMP) 9

GOP-0002 Power Decrease/Plant Shutdown 082

OSP-0034 Control of Obstructions for Primary Containment/Fuel 15

Building Operability

OSP-0037 Shutdown Operations Protection Plan (SOPP) 38

STP-050-0700 RCS Pressure Temperature Limits Verification 309

STP-057-3804 Containment Breach Monitoring 4

Work Order 2825116

71111.22 - Surveillance Testing

Condition Reports (CR-RBS-)

2018-02035 2018-03079 2018-03958 2018-04679 2018-05556

2018-05909 2018-06433 2018-06522 2019-00144 2019-00198

2019-00347

Procedures

Number Title Revision

PEP-0026 Diesel Generator Operating Logs 015

SEP-RBS-IST-1 RBS Inservice Testing Bases Document 6

SEP-RBS-IST-2 RBS Fourth Ten-Year Interval Inservice Testing 9

Program Plan

SEP-RBS-IST-3 RBS Inservice Testing Cross Reference Document 6

SOP-0053 Standby Diesel Generator and Auxiliaries (SYS 309) 339

Procedures

Number Title Revision

STP-051-4504 NSSSS-Reactor Vessel Water Level-Low Low, Level 2; 301

Low Low Low, Level 1, Channel Functional Test (B21-

N682D, B21-N681D)

STP-201-6310 SLC Pump and Valve Operability Test 311

STP-203-0201 HPCS Piping Water Fill and Valve Position Verification 308

STP-205-6301 LPCS Pump and Valve Operability Test 25

STP-256-0201 Division I SWP Valve Lineup Verification 304

STP-309-0201 Division I Diesel Generator Operability Test 062

Work Orders

2609386 52626891 52641960 52660045 52680119 52691959 52709560

2726046 52741308 52756900 52763675 52772829 52788501 52805284

2820064 52834274 52843518 52846504 52849069 52849071 52849859

2850921 52854285 52856057 52856492 52859581

71114.06 - Drill Evaluation

Condition Reports (CR-RBS-)

2019-01520 2019-01583

Miscellaneous

Document

Number Title Date

River Bend Station ERO Team C Site Drill Report 04/10/2019

March 12, 2019

Procedures

Number Title Revision

AOP-0001 Reactor Scram 37

AOP-0052 Fire Outside the Main Control Room in Areas Containing 29

Safety Related Equipment

EIP-2-001 Classification of Emergencies 27

EN-OP-115 Conduct of Operations 26

EN-OP-200 Plant Transient Response Rules 5

EOP-0001 Emergency Operating Procedure - RPV Control 28

EOP-0002 Emergency Operating Procedure - Primary 17

Containment Control

EOP-0003 Emergency Operating Procedure - Secondary 18

Containment and Radioactive Release Control

EOP-0004 Emergency Operating Procedure - Contingencies 16

EOP-0005 Emergency Operating and Severe Accident Procedures 322

Enclosures

71151 - Performance Indicator Verification

Miscellaneous

Documents

Number Title Date

Main Control Room Shift Logs 01/01/2018 -

2/31/2018

Procedure

Number Title Revision

EN-LI-114 Regulatory Performance Indicator Process 15

71152 - Problem Identification and Resolution

Condition Reports (CR-RBS-)

2018-06363 2018-06375

Procedures

Number Title Revision

CMP-1026 MCC Circuit Breakers, Starters, and Thermal Overloads 21

EN-MA-157 Configuration Control 1

EN-WM-107 Post Maintenance Testing 1

Work Orders

00513628 00513629

71153 - Follow-up of Events and Notices of Enforcement Discretion

Condition Report (CR-RBS-)

2018-05854

Procedure

Number Title Revision

STP-051-4524 ECCS/RCIC-Reactor Vessel Water Level-Low Low, 5

Level 2; Low Low Low, Level 1; Channel Functional Test

(B21-N692E, B21-N691E)

AP-0034 Inadvertent Initiation of an ECCS System or RCIC 2

ML19130A200

SUNSI Review Complete ADAMS: Publicly Available Non-Sensitive Keyword:

By: DLP Yes No Non-Publicly Available Sensitive NRC-002

OFFICE ASRI:DRP/C ASRI/RI:DRP/C ARI:DRP/C BC:DRS/EB1 ABC:DRS/EB2 BC:DRS/OB

NAME LMerker BParks TDeBey VGaddy GPick GWerner

SIGNATURE lnm bdp tmd vgg gap gew

DATE 5/02/2019 5/3/2019 4/30/19 4/24/19 4/27/19 04/25/2019

OFFICE BC:DNMS/RIB TL:DRS/IPAT BC:DRS/RCB SPE:DRP/C BC:DRP/C

NAME GWarnick RKellar NMakris DProulx JKozal

SIGNATURE jfk for rlk nfm dlp /RA/

DATE 4/25/2019 4/24/2019 4/27/19 4/30/19 5/10/2019